In November 2012, the Local Government
Association (LGA) published its report
‘Adult Social Care Efficiency programme1;
The initial position’. The report outlined
the approaches of the 54 councils who
had agreed to participate in this two year
programme. It included pragmatic and
aspirational approaches to achieving savings
and improving productivity in adult social
care budgets. This report looks to capture the
lessons from the first year of the programme
(April 2012 – March 2013), and seeks to
assist all councils who are looking to reduce
their spending in adult social care.
At the end of the first year of the programme
councils can be divided into three groups:
• those who have made significant strides
and met their efficiency targets
• those that have worked to better
understand their position and while they
have not yet met their targets they now
have programmes in place to meet them
• and finally those that have made less
progress than they initially expected.
This report focuses on those councils who
have made good progress and the lessons
that may be learned from them. All the
councils which have made returns as part
of this update exercise are covered in this
report.

Efficiency savings
Councils in this programme had to make
savings in a range from 0.4 per cent to 11.3
per cent of their adult social care budget
for 2012/13. The average savings were 5.7
per cent of the budgets. The modal (most
frequently reported) saving was 7 per cent,
which is in line with the recent Association of
Directors of Adult Social Services (ADASS)
Survey of local authority efficiency savings.
The councils were projecting a further 5.7
per cent saving for 2013/14, 5.3 per cent
for 2014/15 and 4.9 per cent for 2015/16
however the figures do not take into account
the impact of the forthcoming spending
review which is likely to increase the
requirements. In addition, those councils
which failed to meet their targets in 2012/13
are likely to face higher percentages for
2013/14.
Councils categorised 50 per cent of their
savings as “reducing bureaucracy” – see
Table 1 below. Examination of the data
revealed that this included a wide range of
interventions including reviewing packages
of care, cutting services and reducing staff
numbers. Councils identified a further 20 per
cent of their savings from managing demand
and 5 per cent from preventive measures.

1 Throughout this report the programme will be referred to as the
ASCE programme or the programme.

4

Adult Social Care Efficiency programme Interim report 2013

Projections for 2013/14 suggested that the balance would shift so that the proportion of
savings achieved through reducing bureaucracy would decline to 43 per cent, managing
demand would rise to 25 per cent and prevention would account for 10 per cent.

A small number of councils were for a variety
of reasons not able to submit a return for the
end of year review.
The return presented particular problems
for groups of councils working together to
deliver a project while others cited “capacity
problems”, often arising from redundancies or
key people leaving the local authority.
This means that the picture is at this stage
incomplete. All councils will be visited in
2014 as part of the final evaluation and as
much information as possible will be gleaned
from them to maximise learning from the
programme.
£800

Level of need

Level of need

While progress has been made in delivering
savings in a number of areas, and early
learning can be seen in subsequent sections,
a significant number of councils within the
programme are struggling to deliver their
intended objectives. Some were late to begin
their implementation phase so report that
it is early days. Others cannot yet quantify
whether and how much saving will be
delivered through their identified approach. In
some cases councils are openly and honestly
saying that they are now behind where they
would hope to be in delivering savings. This
is likely to be impacting on the council’s
overall position and the savings they now
need to deliver in 2013/14.
£3,200

Prevention

Adult Social Care Efficiency programme Interim report 2013

5

2. Lessons learnt so far

Councils in the LGAâ&#x20AC;&#x2122;s ASCE programme
have found that they can deliver efficiency
savings through:

Systematic approaches to a
transformed system
Models of care and interventions that focus
on promoting independence can deliver
better outcomes at lower cost. Officers
need to develop a strong business case
for transforming services in this way. There
is a range of ways in which councils are
now focusing more on interventions that
promote independence, many of which
are being implemented as a payments-byresults approach. The case study produced
with Wiltshire is highlighted in this report
but other approaches in Hackney, Suffolk,
Calderdale, Darlington, Kingston and Kent
all adopt this as a fundamental base to their
transformation programmes. Many councils
have established a review programme often
focusing on higher cost packages of care.
Some councils are working closely with
customers to assist them through support
which will help the person become more
independent and thus need less care in the
future. Other councils are reducing the care
that is available.
Using a strategic partner to provide external
challenge and to undertake a robust analysis
of what is happening in a council can be
useful.

6

Some councils are using strategic partners
to assist with driving transformation to deliver
the scale of savings required. This approach
is further explored later in this report.
One clear finding from this programme is the
better a council understands its demands
and the impact that its current approaches
make on its expenditure the more likely the
council will find further efficiencies.

Specific actions related to
practice and commissioning
Reducing the number of older people
entering residential care through a specific
focus on what happens to older people
leaving hospital. Many councils have adopted
a policy that no one should be assessed
in a hospital bed for a longer term service.
Any assessment should be undertaken in an
Intermediate Care Setting (domiciliary care
reablement based service or a reablementfocused residential care bed) in order to
avoid long term packages of care based
on the individuals at a point of crisis. The
summaries of councilâ&#x20AC;&#x2122;s approaches in
section 4 show that the work in Suffolk,
Northumberland, Cheshire West and Chester
and Hackney can all evidence savings
from this approach. Other councils make
indirect reference to managing admissions to
residential care.

Adult Social Care Efficiency programme Interim report 2013

Establishing a thorough reviewing process
is in place to ensure that the services that a
person is receiving (including in some cases
residential care settings) are delivering the
outcomes that will help the person become
more independent. Hackney have a strong
project management programme which is
monitoring savings as they are delivered.
Many other councils are also adopting
this approach.
Supporting carers and recognising signs
when they are under stress and there is a
risk of breakdown. Failure to do this will cost
money in the longer-term. This is an issue
which came up in the Kingston diagnostic
– see section 5. This work is more related
to cost avoidance than cashable savings.
It acknowledges the estimated £119 billion
worth of care provided free each year by
informal carers.
A focus on diverting customers who do not
need formal social care support away from
council services towards the community
and voluntary sector. This has been hard
to measure in terms of the direct impact of
savings though general evidence of fewer
people in the formal care system can show
the success (or otherwise) of this approach.
Calderdale report savings from this in their
programme.
Improving the reablement service with a
focus on the care pathway to ensure that
everyone who may need longer term care
and support receives a domiciliary care (or
residentially) based care service before they
are assessed for a longer term service.

All reablement services should know and
understand the outcomes they produce.
Developing a joint service model with health
which has reablement at its heart may offer
the most effective way of meeting older
people’s needs including those who have
been recently discharged from hospital.
Many councils report making progress
through a renewed focus on reablement.
Richmond are notable for their joint work with
health services in this area, whilst Torbay
continue their focus on reablement for older
people who already receive care.
A focus on getting it right for self-funders
before they make a decision to enter
residential care can save money in the longer
term for councils. Ensuring that older people
do not make a decision to enter residential
care when there are better community
based solutions open to them. Poole are
amongst the councils to have focused on this
challenge and report some early progress.
Thoughtful use of telecare. It does not deliver
savings in isolation but as part of a focused
intervention which is aimed at promoting
independence. Local authorities are keen
to get a better understanding about which
type of equipment can best be used in which
setting and deliver it in a personal way. One
council is developing the “telecare matrix”
which links the appropriate equipment to the
condition and needs of the service user. Both
Kingston and Luton report early savings from
the better use of this equipment.

Adult Social Care Efficiency programme Interim report 2013

7

Reducing bureaucracy and
on-costs
Reducing the number of buildings from which
councils deliver services, including reducing
office bases, day centres and in-house
residential care. This is a particular feature
of the background to the savings in Wiltshire
and is in process in many places.
Improving procurement. The open book
accounting approach which is being developed
in Yorkshire and Humberside links to the
Department of Health Policy on Market Position
Statements and working with the market, rather
than against it through just holding prices. This
work has been led from Wakefield.
Making more efficient and effective use of
social work time. This is a key part of the
Central Bedfordshire approach and is also
addressed by Kent and Kingston.
Collaborating with partners can deliver some
savings in relation to management costs. The
tri-Borough in the North East (Darlington,
Hartlepool, Redcar and Cleveland) and some
of the authorities working to integrate more
with Health demonstrate this. They are,
however, limited to sharing the cost of posts,
particularly senior posts. Early feedback from
some places questions whether the level
of savings is worth the challenge involved
in putting in place the processes and new
governance structures necessary.
Annex A reports the efficiency savings by
type and gives a number of authorities
reported to be achieving savings in this way.
It is recommended that readers contact
individual participating authorities to find out
further details and share learning.

8

On-going challenges
There are a number of recurring issues that
were identified in “The Initial Report” and are
emerging as on-going challenges to local
authorities. These include:
• leadership
• efficiency savings in learning disability
services
• transition from children’s to adult’s services
and also to services for older people
• evidencing savings, particularly in relation
to integration with health, personal budgets
and transforming transport
• prevention and managing demand.
Leadership
It is noted that leadership is one of the
most critical features for the delivery of
efficiency savings. This will always be a
combination of political leadership, which
has to develop a clear vision and strategy for
what social care will look like going forward
(with less resources) and officer leadership.
There are already risks emerging in this
programme in councils where the leadership
of the programme within the council or
the sponsoring senior management has
changed. Councils need sustained and
persistent leadership in delivering the
transformation that is associated with
delivering efficiency savings; single changes
are inevitable but wholesale management
team turnover is a significant risk to
sustainable delivery.

Adult Social Care Efficiency programme Interim report 2013

Learning disability services
As highlighted in our previous report it is
in learning disability services that councils
continue to face the greatest challenges
arising from increases in numbers, life
expectancy and costs. The new models that
are emerging for other service user groups
(reablement for older people; recovery in
mental health services; rehabilitation for
disabled people and those recovering from
substance misuse; etc) have not developed
fully in the learning disability field.

In addition to focusing on the transition
from children’s to adults’ services Croydon
are also looking at the transition from adult
services to services for older people and a
further transition group has been identified –
mid-life people who have traditionally been
cared for by their families but for whom that
is no longer possible due to old age and
infirmity. Croydon see carer support and
forward planning as key to avoiding costly
interventions and providing the best solutions
for these groups.

The work being done in Croydon within this
programme is therefore of much interest to
the sector. The sense at present within the
programme is that councils have made some
progress with reducing costs, particularly
in reducing costs and numbers of people
in residential care, reducing the amount
of community support some people get,
tightening of the application of eligibility
criteria and getting out of buildings for day
opportunities.

Evidence of savings
Those places that hoped to achieve
that efficiency savings through health
and social care integration have so far
been disappointed that they are not able
to evidence the savings. Where health
and social care have worked together to
achieve specific outcomes i.e. in improving
reablement or other out of hospital care
services there is some evidence of
efficiencies and better outcomes being
achieved.

Some councils have looked to use
employment schemes to help offer people
useful activity during the day with some
income available to both fund the activity and
to pay an allowance to the worker. These do
not appear to offer sufficient momentum for
workers to assist them into permanent jobs
which is the long term goal.
Transitions
It is interesting to note that only Croydon
Council has wanted to explore the
challenging area of transition from children’s
to adults’ services within this programme.
This is often an area where councils identify
challenges in both the levels of funding
for new packages of care and meeting
the expectations of carers and sometimes
customers.

In the Northumberland Care Trust there has
been a 7 per cent reduction in the numbers
of older people in residential and nursing
care. This is in line with reductions made
elsewhere within this programme but it will
be interesting to explore in the final report
what proportion of the reduction could be
attributed to the integrated service model.
While no one in the programme has yet
demonstrated that personal budgets deliver
efficiencies, there are some anecdotal stories
of savings. However most of these focus
on a change of care setting which could be
achieved without a personal budget.

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9

There are some risks that the arrangements
for framework contracts associated with
customers arranging their own packages
of care can allow prices to increase in an
uncontrolled way.

Recent work from the Institute of Public Care
(Oxford Brookes University) has identified
the approaches that councils may take to
“prevention” and these are mostly contained
in the programme:

There are many reports of councils reducing
the care packages that people receive and
this is reflected in a reduction in the amount
of money available through a personal
budget.

• Universal provision – the preventative
aspects of universally available services.
A focus on the wellbeing of the population,
keeping fit and well with a healthy diet and
positive wellbeing. This will include a focus
on improved health outcomes that may
reduce demands for social care. It should
feature strongly in Health and Wellbeing
strategies that are currently being drafted.

Transforming transport services appears
to be a challenge for most councils. Most
approaches focus on how a personal budget
with a citizen contribution (reducing the
previous levels of subsidies) can deliver this.
Prevention and managing demand
Many argue that in order to deliver the
level of savings required now and into the
foreseeable future there needs to be a
radically different approach to social care.
The most common model that is emerging
from within councils is one which focusses
on prevention and managing (and rationing)
demand.
This approach is clearly evident in the
programme – the work in Hackney, Suffolk,
Kent, Kingston, Wiltshire, Bradford, Torbay,
Calderdale, Waltham Forest and South
Tyneside all demonstrate strong elements of
this approach.

• Preventative provision for populations
that contain some elements of
vulnerability – specialist services that
may tackle some aspects of need but not
ones which would have led to an assessed
social care intervention. Many of the former
supporting people funded services would
fit the bill. The Department of Communities
and Local Government’s programme for
payment by results reinforces how this
approach could be truly preventive.
• Targeted restorative interventions –
interventions targeted on very particular
populations in the evidence based belief
that if successful they will lessen potential
future demand for high intensity care. This
includes the future for reablement and
recovery based services.
• Deferred interventions – interventions
that are preventative in that they defer
people for a time from a poorer outcome.
This might include early diagnosis of
dementia and putting in place support
arrangements which will enable the person
and their carer to remain together for a
longer period.

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Adult Social Care Efficiency programme Interim report 2013

If a focus on prevention as outlined above is
linked to a focus on outcomes that promote
independence as outlined in the Hackney
Council Mayorâ&#x20AC;&#x2122;s Compact for Social Care the
basis for a transformed and efficient model
for social care emerges.
The model balances a focus on rights but
with responsibilities. It offers a compact
for the person who needs care where the
state will offer a set of solutions developed
with the customer where promoting their
independence is the basic assumption.
The model will focus on interventions that
assist people to resolve the crisis that they
face based on recovery and restoration. The
aim of social care will for the first time be
preventive â&#x20AC;&#x201C; an emphasis on helping people
where appropriate to stay out of formal care
and to build on capacity in communities and
in the voluntary sector.
This report captures the end of the first
year of a two year programme. The final
evaluation and report will be produced in
the summer of 2014. Building a stronger
evidence base for prevention will be critical
to the overall success of this project.

Adult Social Care Efficiency programme Interim report 2013

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3. The value of challenge

A number of councils in the programme have
adopted a strategic partnering approach
– Hampshire, Coventry and Peterborough
have established partnership arrangements
with Ernst & Young, Price Waterhouse
Coopers and SERCO respectively as part of
a corporate savings programme. Cheshire
West and Chester also report that they have
engaged with a strategic partner.
Other councils have longer term
relationships with consultancies such as
OLM (Portsmouth, Stockport, Swindon);
IMPOWER (Bradford and Calderdale);
Charteris (Liverpool, Warrington and Wirral
and Central Bedfordshire). A further group
of councils have appointed consultancies
on a short term basis to assist with specific
pieces of work such as the former Berkshire
Authorities; Cheshire East, Hackney,
Lambeth et al. The following consultancies
have also contributed directly to the
programme – People Too; Institute of Public
Care; West Midland RIEP; iESE; Alder;
Red Quadrant; Atlantic; Helen Sanderson
Associates; KLG Consultants; Outcomes
UK and PA Consulting. There may also be
other arrangements which have not yet been
reported to this programme.
One approach that has been adopted by
two very different types of council in the
LGA programme was to select an “efficiency
partner” to work with them to assist in
meeting their savings targets. The approach
adopted by Kent and The Royal Borough
of Kingston has developed as a direct

12

response to the original brief set out by the
LGA in the programme. That was to invite a
consultancy to undertake a diagnostic and
then to use the information to assist with
transforming services. These councils have
taken this further. Interestingly they adopted
the same process and at the end they have
both chosen the same partner, Newton
(Europe) a company that did not have a long
track record in social care but a much wider
reputation in both industry and the health
sector.
At the beginning of the programme (with the
£20,000 grant from the LGA) both councils
chose an organisation to assist them to
undertake a diagnostic of their current
activity and data to identify areas where
savings could be made. A detailed analysis
of the activity and performance of the council
was presented with an estimated savings
figure shown for each part of the analysis.
The councils then went out to tender to select
a “transformation and efficiency partner”. The
work of the initial diagnostic was offered to
all those organisations who were interested
in bidding for this phase of the work. Bidders
for this phase had to demonstrate their
ability to deliver the savings, not to do further
diagnostic work.
The decision to bring in a partner to
assist with delivering savings is seen as
controversial in some local authorities and
may be described as a sign of failure by
some - “why can’t our officers deliver the

Adult Social Care Efficiency programme Interim report 2013

required savings, it’s what we pay them
to do?” is what some councillors may say.
Those who work in the private sector may
be more familiar with this efficiency model
than the public sector where those appointed
to a senior post are expected to be able to
deal with everything that is thrown at them
including day to day management! There
was much political debate before the final
decisions were taken to adopt this approach.
In fact within the LGA ASCE programme
another council, Hounslow, decided that
having received a full diagnostic from
Newton (Europe) they determined that
the transformation needed to be driven by
the managers working within the council
(alongside a neighbouring Borough,
Richmond, who are also part of the LGA
programme) and local health services. Later
in this section the pros and cons of this
approach are considered.
The report to the Cabinet in Kent on 23
March 2013 sums up this debate for the
County Council:
“KCC’s financial deficit over the next two
years (2014-16) is estimated at around
£200m and it is clear that public spending
will remain under pressure for a number of
years. As adult social care is a third of KCC’s
non-school budget, Families and Social Care
is preparing to make significant savings over
the coming years. The basis of the Adult
Social Care Transformation Programme
is that savings of the magnitude that will
be needed can only be achieved through
transformation (re-designing how social
care is delivered). This approach was set
out in the Adult Social Care Transformation
Programme Blueprint and Preparation Plan
which was endorsed by the County Council
on 17th May 2012.”

The Kent report describes how they saw the
process rolling out and why they decided
at the final stage to select Newton as their
efficiency partner:
“In October 2012 an independent efficiency
review was undertaken. Based on the
considerable amount of detailed analysis,
this evidenced that significant opportunities
exist for adult social care to transform as well
as to help support achieving savings of the
order of £18m in the first year.
KCC does not have readily available
capacity of appropriate capability to manage
a programme as large and as complex
as Kent’s Social Care Transformation
Programme.
The expertise of the consultancy used during
the review, and the way they worked with
KCC staff, was a positive and successful
experience. This gave KCC confidence
that it was possible to work in partnership
with a consultancy. It also gave KCC clarity
regarding the added value a transformation
and efficiency partner could bring to the
implementation stage of the programme and
ways of sharing risk.
Transforming social care will be a complex
and time consuming task – taking at least
4 years. This change programme will be
resource intensive and require KCC to
transform the business, whilst simultaneously
ensuring we continue to meet our statutory
duties.
The complexity of improving outcomes
for vulnerable people in Kent, building a
sustainable social care market which is fit
for the future, whilst simultaneously working
within reduced budgets is a huge challenge.
KCC intends to reduce the risks associated

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13

with managing a programme of this size
and complexity by: a) using a consultancy
with enough capacity to support our
programme; b) using a consultancy with a
high level of expertise and with experience in
implementing similar programmes elsewhere.
Without a transformation and efficiency
partner KCC’s ability to transform adult social
care will be severely hindered.
If a transformation and efficiency partner
is not appointed – KCC will need to fully
resource the programme alone. As KCC
does not have enough staff with the
composite skills and experience, a significant
proportion of this resource will need to be
recruited externally. As resources are likely
to be recruited individually, it will take time to
build a team and for them to get up to speed
and work in consistent and co-ordinated way.
This will mean a delay to implementation
starting and therefore a delay to the
realisation of the benefits.”
In Kingston the process happened earlier in
the year and progress was reported to the
last LGA ASCE event in November 2012.
Kingston is a relatively small council and had
been working on becoming more efficient
for several years through the “One council/
One Kingston” programme, enabling the
council to live within its reduced resources.
The challenge of making further significant
efficiencies from adult social care is a major
one. Councillors are very keen to maintain
front line services, so knowledge, expertise
and resources are necessary to look for
ways to further improve processes and
commissioning. The council did consider
whether this could be sourced in-house,
but this presented significant difficulties.
Recruiting and maintaining a team of people
to deliver the efficiencies is a significant task

14

in itself, moreover the external challenge has
been seen as key to delivering efficiencies.
The process of tendering for a partner was
based on the view that Kingston needed extra
capacity, with a level of skill and knowledge
not available in-house and that the challenge
such an approach offered was positive.
Newton Europe was the successful bidder.
They began work on the programme at the
end of November 2012, since then good
progress has been made and benefits are
beginning to be identified and agreed. A key
decision was to co-locate the Newton Europe
team with the adult social care management
team in Kingston. Simon Pearce, Head of
Adult Care highlighted the importance of this
collaborative approach between the local
management and Newton Europe which he
considers to be key to effective working of
the programme.
The fee paid to Newton (Europe) is
determined on the outcomes of the work,
so payment is contingent on savings being
delivered. From the council’s point of view
there is a risk and reward strategy here.
The rewards paid to Newton (Europe) if the
full savings are delivered are high and as
such are likely to attract local media interest.
However, the payment is a “one off” and is
a relatively small proportion of the savings
that have to be delivered. The savings are
delivered in a certain time frame but once
the transformation has been implemented
the money should be taken from the system
for the ensuing years and the savings to the
council are thus quite significant. Every £1
million delivered in Year One becomes £3
million saved by Year Three.
The county council were very clear that the
delivery of savings would require a culture
change from within the organisation.

Adult Social Care Efficiency programme Interim report 2013

They specified that all learning was shared
and transferred during the programme
from the consultants to staff in order to
help ensure that the transformation was
sustainable.
Councils who have looked to develop
a partnership have usually chosen an
organisation that can demonstrate an ability
to both “get into the data” and analyse and
interpret it in a way that can demonstrate

how efficiencies can be delivered. A key
lesson within this programme is that
councils are more likely to find savings if
they understand their data, understand the
impact that their current approaches have on
managing demand and are open to looking
to alternative approaches that might deliver
better outcomes at lower costs.
So what might be the pros and cons of
adopting this approach?

Table 2: Advantages and disadvantages of the approach
The Advantages
The efficiency partner takes away some of
the responsibility and burden of delivering the
savings and allows the council to focus on
meeting the needs of local citizens.
The efficiency partner brings new skills and
knowledge which is unlikely to exist in the
council (even a large council such as Kent).
The ability of the efficiency partner to
understand the data and interpret how it leads
to greater efficiencies may not be available
within a council.
The project management approach that skilled
consultancies bring to local government is still
an emerging skill for councils, particularly in
adult social care.
The need for external challenge is being
seen as a critical part of the LGA programme
– without that challenge many councils are
finding it very hard to make the changes
required to deliver the budgets that they have
been set.
There is a lot of talk within adult social care
that further efficiencies cannot be made. The
consultancies are proving otherwise.

The Disadvantages
Transformation is dependent on the culture
of an organisation as well as the delivered
changes – local managers are often best
placed to understand the culture and deliver
the changes required.
In the longer run those skills are required by
the council to both sustain and continue with
the new transformational models that are put
in place
Concern that the consultancy will only tell us
what we already know?

Democratic accountability is an important part
of the local political process – any changes
that are proposed need democratic support
from local members – that can only be
delivered by their paid officials.
The LGA has already developed a model of
Peer Challenge to assist with the need for
external scrutiny.

Will the efficiencies being delivered in
the short-term be sustainable longer term
particularly as the demographic pressures
beginning to manifest themselves in Health are
sure to hit social care very soon.

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15

If councils carry on doing things in the way
in which they have always done things it is
unlikely that they will be able to make the
efficiency savings required. It needs a total
transformational approach to the whole
system. This may require some people to look
at the challenges with a fresh pair of eyes.
Payment can be set up in a way that makes
it contingent on the level of savings required
being delivered: No win, no fee. This is the
best guarantee a council can get.
This is a competitive market with several
potential partners – chose the partner carefully
and the process should work for both sides.
The approach has proven to identify significant
savings in two ASCE authorities, however
there has been no evaluation as to which
approach offers the best outcomes (see an
alternative below).

Self-challenge and peer
challenge
The Towards Excellence in Adult Social Care
Programme, Think working with Local Act
Personal Programme has recently launched
a self-assessment tool to assist councils
with their self-evaluation around “use of
resources” in adult social care. This not only
updates the original DH Publication, Use of
Resources in 2010 but adds a tool which
guides councils to challenge themselves
about the progress they are making.
The resources and tools can be found on the
TLAP website: www.thinklocalactpersonal.
org.uk. For those councils who want
to develop an approach through selfassessment and peer challenge these are
the most recent products available. The LGA
and ADASS will be using these tools as part
of the peer-challenge process.

16

The figures that are paid out at the end of
these partnerships can be high (into millions
of pounds) – can this be justified to the local
population when we are making savings.

Consultancies vary – some diagnostic skills
are basic and delivery skills are poor when
tested on the ground.
The TLAP model, highlighted below, offers
an alternative approach through both peer
challenge and self-assessment. This will
provide external challenge without a significant
cost.

They support the on-going efficiency work
that many are continuing to undertake and
will be of interest in the programme going
forward.
• A Problem Shared: Progress in
delivering budget savings in adult
social care 2007/8 - 2011/12
http://tinyurl.com/mrulznj
This report presents and analyses national
data on how councils have spent their
budgets in adult social care over the last
four years - and especially during the
period since the 2010 Spending Review.
It compares changes in expenditure with
changes in activity, costs and income over
the same period.
• Self-assessment tool
http://tinyurl.com/lsk2fwa
This self-assessment tool is broadly
based on the framework provided by the
Association of Directors of Adult Social
Services (ADASS), “How to Make the
Best Use of Reducing Resources: A whole

Adult Social Care Efficiency programme Interim report 2013

system approach”. It can be used on its
own, or with the other optional tools in
the toolkit.
• Guide to the self-assessment toolkit
http://tinyurl.com/kvb5ekr
This guide explains how to use the selfassessment tool and the other optional
tools, which include the descriptors of
“What good looks like”, examples of
“Relevant nationally-available metrics”, and
other “Useful resources and guidance”. We
know that many councils are carrying out
wide-ranging reviews of all departments
including adult social care.
• Use of resources information template
http://tinyurl.com/l3nlvo5
This information template will help
councils assemble the important data and
background information they need before
getting started with the self-assessment
process.
• Optional Tool 1: What Good Looks Like
http://tinyurl.com/l3plk6w
This optional tool describes “What Good
Looks Like”, based on recent research,
guidance and case studies from across
England. Councils can choose to refer to
these descriptors when completing their
self-assessment tool.
• Optional Tool 2: Relevant nationallyavailable metrics
http://tinyurl.com/lrltvfg
This optional tool lists metrics that
are currently collected nationally, and
that councils may choose to use when
completing their self-assessments.
However, it is acknowledged that better
indicators and a stronger evidence base
are needed to assess the value for money
of adult social care services.

• The toolkit comprises: – Optional Tool
3: Useful resources and guidance
http://tinyurl.com/n2z5rto
This list of useful resources and guidance
is designed to support the use of the
self-assessment tool. It focuses on
publications, guidance and tools that have
been produced in the UK since 2009.
Many councils in the programme have not
yet delivered the scale of transformation
required and are behind in their programmes
to deliver the savings projected – this is
threatening the stability of both social care
and the overall finances in some councils.
Evidence from participating authorities on
the LGA programme suggests that external
challenge is a really positive way in which
councils can explore new ways of thinking
and find new solutions to their problems.
The approach taken by those working with
an efficiency partner demands serious
consideration. The list above identifies
some of the risks but councils can ensure
that they have looked to take actions that
mitigate these risks (this is mostly done in
the process to select the right partner). We
would encourage Councils to consider one of
these approaches. We will continue to share
information on the progress made and any
lessons that emerge over the coming year.

Adult Social Care Efficiency programme Interim report 2013

17

4. Summary of progress
2012/13 by council
This section contains a summary of the
progress that was self-reported by Councils
to the LGA in March 2013 (the end of the first
year of delivery of the programme). There
are two more detailed case studies that are
written up at the end of this section. These
relate to the Royal Borough of Kingston
and Wiltshire Councils whose work was
highlighted at the first programme event in
November 2012. They both show excellent
examples of how councils are tackling their
challenges in different ways.

Bradford Metropolitan District
Council
The first phase of the work in Bradford
focussed on the ‘Use of Resources’ which
considered how to reduce spend on higher
cost residential care as well as achieving
savings in procurement costs of individual
care packages, changes in providers,
management savings and through greater
use of technology.
It took until September 2012 to clearly
develop Phase 2 of the programme which
identifies further efficiency opportunities
to help in planning for 2013/14 and
beyond and incorporates a greater focus
on the potential for behaviour change
and demand management. In particular,
the recommendations in the report are
being used to assist with achieving the
efficiencies required from our current Access,
Assessment and Support programme

18

(A&AS) which is already showing progress
and is ahead of schedule. The Access,
Assessment and Support service was
allocated £300,000 of growth money in the
2012/13 budget settlement which, as a result
of accelerating changes within the service
in line with the Improvement Programme,
was not required. As well as this the A&AS
service achieved its recurrent savings target
of £600,000 and indeed achieved a further
£168,000 compensatory savings which will
be released to fund vacancies in line with the
changes identified in the A&AS Improvement
Programme.
Overall across adult services the savings
target for 2012/13 was £8.68 million and
whilst not all the savings targets have been
fully achieved, alternative savings were
identified. The majority of these are one-off
in year savings 2012/13 and the budget was
balanced at 31 March 2013.

Calderdale Council
Calderdale have been working more closely
with customers, the voluntary sector and
other partners to promote independence
and divert people away from the social care
system.
Savings of £2.1 million have been made
in 2012/13, 3.6 per cent of the net budget,
which brings the service in under budget.
The majority of the savings have been
achieved by taking a more rigorous approach

Adult Social Care Efficiency programme Interim report 2013

to pursuing re-ablement and the subsequent
allocation of funding for individual care
packages. Further savings were achieved
by reviewing the skills mix and make up
of teams, a review of in house services
and better procurement and contract
management.
A further £3.1 million efficiency saving is
projected for 2013/14 (5.6 per cent of the net
budget). This will be achieved through further
modernisation of the customer journey,
including the introduction of a resource
allocation system and putting into place more
effective and efficient alternatives to out of
area placements. The Council will continue
their commitment to look for new ways of
delivering in-house services including home
care maintenance, day services and extra
care services as well as decommissioning an
intermediate care facility.

Central Bedfordshire Council
Central Bedfordshire Council worked with
a consultancy to look at how older people’s
care needs can change over time with a
focus on those who recover. This has led to
a fresh approach to reviewing services – the
review can focus on whether the person has
recovered and if the service on offer is now
the best service for them or whether there
are more effective ways of meeting needs?
The review looks at the specific needs of the
customer and where they are in their life.
While it is early days in terms of measuring
efficiencies the approach has helped to
change the mind-set of those involved in
reviews.

Further work will develop examining the
productivity of staff with a view to making
more efficient use of social workers time.
This has helped to meet the target of 7.4 per
cent efficiency savings in 2012/13. Future
savings targets are 7.39 per cent and 5.7 per
cent for 13-15.

Cheshire East Council
A consultancy has continued to assist the
council with residential and community fee
negotiations, including implementing a quality
framework for future contracts. The council
has benefited from a positive relationship
with them and have continued to utilise
their support, for example in the completion
of an accommodation needs review. Most
recently the council has also engaged, on
a pilot basis, with “Skylakes” to review and
reassess a sample of 50 individual’s cases,
the aim being to assess whether external
scrutiny might provide an insight into internal
practice. Early indications suggest there are
reductions in care plans and costs. During
the remainder of 2012/13 a combination of
remedial measures have helped to mitigate
the extensive spending pressure, some
of these actions have been continued into
13/14, whilst a larger programme of change
is put in place.
The savings target of £6.6 million (7.2 per
cent of the £91.5 million net budget) has
been met for 2012/13. Projected savings rise
to 10.38 per cent for 2013/14 and then 4.3
per cent for 2014/15.

Adult Social Care Efficiency programme Interim report 2013

19

Cheshire West and Chester
Council
The council aimed to assess the service
against the vision expressed in the document
“Shaping the Future Together”.
The consultancy which was appointed to
undertake the assessment has been retained
to implement phase 2, which aims to ‘set the
platform for an engagement strategy which
develops the existing network and enables
it to be more self-sufficient, inclusive and
influential’. Phase 2 only began in February
2013 so it is very early days in terms of
delivery.
£3.74 million of efficiency savings were
achieved in 2012/13 (4.1 per cent of the net
budget). £0.6 million is projected for 2013/14.
The council aim to achieve a 15 per cent
reduction in residential care of older people,
however changes to hospital discharge will
influence this.

Coventry City Council
The focus of the work in Coventry was
changed after the initial diagnostics stage, to
embed the use of technology into the overall
Adult Social Care Transformation programme.
Also to look at where further efficiencies might
be identified within particular service areas, eg
Home Meals, Home Support, and reablement /
promoting independence, etc.
£2.1 million of savings have been achieved
over the last 12 months through the
outsourcing of the home meals service,
closure of day provision in two under-utilised
resources, de-layering of management
structures and improvements to the
commissioning process.

20

For 2013/14 ‘a bolder community services
programme’ has been implemented based
on the principles of building resilience and
encouraging independence as a preventative
approach. The programme aims to save £3
million over the coming year.

Croydon Council
The project aims to address the significant
costs in supporting Learning Disability
clients. It is focussed on two main elements:
a) addressing customer/family expectation
and case management cultural change.
Alder, the external consultancy engaged
to support the work were focused on three
strands – data analysis, practice analysis
and strategy analysis. Data analysis looked
at both national data for benchmarking
purposes and developing initial lines of
enquiry, and local data to confirm current
performance and potential areas for
improvement. Practice analysis included
examination of case files and interviews with
practitioners and commissioners to better
understand current practice and how to
develop it to meet key strategic objectives
and deliver improved outcomes for people.
Strategy analysis also included health and
housing colleagues to develop an integrated
and coherent strategy in respect of these
services. The approach aims to better
support clients towards an ordinary life and
better manage risks.
The analysis has highlighted some strengths
and a number of areas that need to be
addressed, including communication skills
and dealing with expectations being primary
among those.

Adult Social Care Efficiency programme Interim report 2013

Transitions have also been highlighted as an
area for development and not just transition
from children to adult services or adults
to older people, but a further “transition”
group has been identified. The new group
includes those mid-life individuals that have
been cared for by families but for whom
that is no longer possible due to infirmity
and old age themselves. This group often
trigger emergency solutions due to little or
no warning of breakdown of the existing
arrangements and often lead to costly
support due to the lack of forward planning.
During 2012/13 savings of £6.3 million were
made across adult social care as a whole,
6.3 per cent of the net budget. Similar levels
of savings are projected for 2013/14 with
a further £4.6 million, 4.8 per cent of net
budget for projected for 2014/15. In the
current year savings have been achieved
primarily by reducing staffing layers in the
council, introduction of assistive technology
in learning disability supported living
services, re-shaping of older peoples day
care model to provide reablement focused
resources centres and greater alignment with
OT services, reviewing care packages and a
review of transport arrangements for people
with learning disabilities.
Delivery plans will continue be implemented
in 2013/14 with the introduction of life
coaching targeted at learning disability
customers in transition.

Cumbria County Council
The council has commissioned a Managed
Service Provider, Cumbria Community
Foundation, to fund prevention activities in
the county.

This is called the Neighbourhood Care
Independence programme and is based
upon Asset Based Community Development
approaches to building community
capacity. The provider began the grantmaking process in October 2012 in order
to grant fund prevention activities with
£867,000 per year for three years from
April 2013. Decisions on which third sector
partnerships of organisations would receive
grants were made in January 2013 and
the Neighbourhood Care Independence
programme began in April 2013. The
hypothesis is that by investing in these
activities, eg advice and information,
help with low level equipment, volunteer
befriending, handy person and home from
hospital support schemes that the need for
adult social care services can be reduced,
avoided and delayed. A consultancy, Institute
for Public Care, has been appointed to fully
evaluate outcomes and effectiveness of the
programme during 2013/14.

Durham County Council
The diagnostic phase identified a number
of suggested savings aimed at managing
demand for services, which have been
incorporated into the Council’s Medium
Term Financial Planning processes. These
include increased use of intermediate care;
expansion of telecare service; supported
living remodelling; review of day care;
effective targeted commissioning of high cost
packages; policing current eligibility criteria;
charging review; expansion of reablement
service and reduce transport costs.
£7.5 million of efficiency savings were made
in 2012/13, 4.8 per cent of the net budget.
Further savings of 3.3 per cent are projected
for 2013/14.

Adult Social Care Efficiency programme Interim report 2013

21

Gateshead Council

of confidence for achieving a further £4.5
million in 2013/14.

A brief report was received from Gateshead
showing that £75,000 of savings had been
identified through their prevention programme.

Hampshire County Council

London Borough of Hackney

The original aim of the work in Hampshire
was to look at efficiency savings gained
through a focus on telecare, day care and
transport.

The council formed its second Transforming
Adult Social Care programme in late
2012 which is driven by an overarching
commitment to better promote
independence. This was agreed by members
and published as a clear statement. The
programme incorporates projects focusing on
re-ablement, preventative services, universal
services, day care, directly provided
services and integration. The project delivery
approach is combined with a continued focus
on workforce development, personalisation
and user and carer involvement.
The agenda is supported corporately through
a dedicated Adult Social Care Budget Board
which is chaired by the council’s chief
executive. The board monitors in-depth
budget and performance information on a
monthly basis. It also supports delivery of
the programme. this year care management
capacity was enhanced to undertake care
management reviews in priority areas and
work was undertaken with Ernst & Young
to develop long term financial and demand
modelling.
The programme has delivered all its
key milestones in its first year toward its
overarching aim to deliver its medium
term savings target through an agenda for
promoting independence. In particular it is
on track to achieve its £5 million savings plan
for 12/13 (4.8 per cent of its net budget) and
starts the new financial year with a high level

22

Following extensive partner consultations the
decision was taken to develop a business
case for the adoption of a strategic partner
for the delivery of mainstreaming telecare in
Hampshire. The partner will drive a cultural
change programme to embed telecare
across the county, acting as the primary point
of contact for all telecare provision. They
are currently at the implementation phase
prior to starting on 1 August 2013. Work has
been progressing on a long-term transport
commissioning strategy which ensures
that transport arrangements complement
changing demand arising from service
transformation in learning disability and older
people’s services. The forecast savings
target is currently being estimated but will be
linked to a range of different areas of activity,
including:
• insourcing transport provision and
maximising the use of in-house vehicles,
through additional driver recruitment and
looking at more shared journeys
• direct payments for transport
• working with care managers to ensure
they implement better checks to manage
demand
• travel training for those who could use
public transport with some initial support
and guidance.

Adult Social Care Efficiency programme Interim report 2013

Overall, £15.2 million efficiency savings have
been achieved in 2012/13 (4.5 per cent of
net budget) with a further 1 per cent saving
projected for 2013/14.

Havering, Barking and
Dagenham and Redbridge
Councils

To support early intervention and
preventative work local voluntary sector
groups were helped to develop the support
they can offer to older people, especially
those who are at risk of losing their
independence but do not currently meet
the criteria for adult services input. The
work included compiling a directory of local
services and helping to create new groups
where gaps in provision were identified.

The objectives of the joint project were to:

The council is providing reablement services
to older people in crisis to maximise the
clients’ independence and minimise ongoing
care costs.
Older persons’ day opportunities are also
being reviewed with a view to consulting
widely with older people and their carers
prior to retendering the service next year.
In the meantime, some innovative day
opportunity pilots are underway, including a
joint project with Rushmoor Borough Council
to provide day opportunities for older people
from the Nepalese community in North
Hampshire; a carers’ service at Malmesbury
Lawn day centre; and funding for the Gosport
Live at Home Scheme (which provides
befriending, a coffee morning, lunch club,
advocacy, and outings).

1. Jointly identify, develop and implement
opportunities to achieve financial savings
and wider benefits through cooperation
and working together around the key
points of the health and social care
interface. This is particularly in relation
to older people and pathways out of
hospital, given our shared dependency
on discharge arrangements with the local
acute health services including Queen’s
Hospital, Romford.
2. Explore and create opportunities and
initiatives to develop community based
and preventative care to support the
reshaping of acute and secondary health
provision through close joint working
across our boroughs and with health.
The work aims to improve arrangements for
Integrated Care across Barking, Havering
and Redbridge (BHR), to deliver both policy
objectives, in the achievement of integrated
delivery and improved outcomes, and to
improve management of demand within their
system. A key priority has been to seek ways
through which current reliance upon higher
cost bed based services including those
within an acute setting might be addressed.
This is a particular issue not least as their
JSNA readily evidences increasing numbers
of people who are older frailer and with one
or more long term conditions.

Adult Social Care Efficiency programme Interim report 2013

23

The work to develop the approach to
Integrated Care has been support by Ernst
&Young and early modelling has been
undertaken in relation to requirements for reinvestment into community services.
In addition to the above, Havering, working
with its partners, established a range of
projects designed to improve efficiency and
help to improve management of demand.
These include:
1. Detailed review of why residential
placements are made with a view to
enhancing the use of alternative solutions
including those of community support.
This area of work has a savings target
in of £400,000 in 2013/14 and a further
additional £600,000 in 2014/15.
2. Increasing re-ablement capacity to
ensure greater levels of inclusion,
independence, self-care and
management and reduce demand for
higher cost long term services.
3. Establishing a Help not Hospital
scheme, designed to provide support
to people presenting unnecessarily to
hospital who need support to return
home but fall under the council’s eligibility
for support. Forty people are currently
supported through this service.
4. A pilot to use telehealth for patients
with Chronic Obstructive Pulmonary
Disease which has been shown to impact
positively upon A&E related costs. For
the sample group of approx. 20 people,
A&E costs were £121,509 in the year
before intervention and only £68,224 post
deployment of the scheme.

24

5. Significantly increasing our use of
Assistive Technology to provide
alternatives to traditional support and
where intervention is time sensitive.
6. We are currently developing a selffunders strategy – which will ensure
that self-funders have timely access to
information and advice about how their
care and support needs might best be
met and the choices available to them
within the local market at equitable prices.
The indicative business case identifies
potential savings in excess of £300,000.
Redbridge have made efficiency savings
of £3.03 million, 4.5 per cent of the net
budget for 2012/13. Savings to date were
achieved through contract re-negotiation,
decommissioning, market shaping. The
projected savings for 2013/14 is £2.96
million, ie 4.4 per cent of the net budget.
They aim to achieve this through increased
reablement service both through hospital
and community referrals through external
providers leading to reductions in long term
placements and/or care hours for users;
promoting more take-up of cost effective
personal budgets offers through individual
service funds and direct payments; more
coordinated work with health (and thereby
supporting service users through one
coordinator, one shared support plan and
review for both health and social care needs)
through the integrated case management
teams based across GP clusters based on a
pioneering risk-stratification tool.

Adult Social Care Efficiency programme Interim report 2013

Kent County Council
Since the adult social care transformation
plan was agreed by the County Council
in May 2012, work has been done to
understand the many elements of Kent adult
social care business and how transforming
one element could impact others.
During October 2012, Newton Europe
carried out a diagnostic on Kent adult
social care. They worked closely with
staff across the whole social care system
to evaluate the way care and support is
assessed, commissioned, procured and
delivered. Findings included:
1. Care Pathway: A greater number of
people could be supported to be more
independent through short term, intensive
services such as the Kent Enablement
Service and a broader range of telecare
equipment.
2. Optimisation: Whilst the adult social
care workforce works very hard, some
of the working time is not as productive
as it could be. This is due to complex
processes, excessive paperwork and
burdensome systems.
3. Commissioning/Procurement: The
very large number of providers we have
contracts with in Kent makes it difficult for
us to communicate with and work closely
with all our providers.
These issues will be addressed as part of
the transformation programme. In December
2012 the council went out to tender for an
efficiency partner to work in partnership on
a risk/reward basis to provide support with
the implementation of the Transformation
Programme.

This process is now complete. Newton
Europe were awarded the contract and
started working with the council in May 2013.
During 2012/13 the council made 2.8 per
cent efficiency savings (£9.48 million).
The majority of the savings were achieved
through a review of residential and
supported accommodation and domiciliary
care. A further £1.6 million of savings were
achieved through an increase in enablement
reducing the need for on-going packages
of care and reduced number of people
entering the system. Nearly £1 million was
saved through streamlining back office
functions, management structures and
improving commissioning and procurement
practices. Projected savings for 2013/14
rise to £18.8 million, 5.6 per cent of the net
budget.

Royal Borough of Kingston
The Adult Social Care Team has taken a
twin track approach to achieving efficiencies
and service improvements. An internal
improvement programme has been making
significant savings since 2008 and by 2010
had achieved savings of £1 million, largely
through a review and reduction of staff
numbers. An integration project is on-going
to deliver services jointly with healthcare
colleagues through Your Healthcare, a
community interest company, and other key
workstreams include the recommissioning of
day-care services and the establishment of
a social enterprise to deliver supported-living
services. In total the programme is set to
deliver sustainable savings of £3 million by
2014/15.

Adult Social Care Efficiency programme Interim report 2013

25

The council also engaged with Newton Europe
Ltd in March 2012, using funds under the
LGA efficiency programme, to undertake a
diagnostic of further service improvement and
savings opportunities. Subsequently Newton
were also selected to deliver a programme
of savings totalling £2.7 million (5 per cent
of budget) that started in December 2012
and focusses on two key themes: making
operational changes to increase the range
and use of telecare, reduce reablement costs
and increase numbers using the service; and
provide more timely reviews of service for
older people and younger people with physical
disabilities. Commissioning work is also ongoing to re-commission home-care services,
review the costs associated with high-cost
packages of care for people with learning
disabilities, and reduce the prices paid for
nursing and residential care. The programme
is currently on schedule and the council has
recognised £459,000 of savings to date. The
programme is due to complete in March 2014.

• the successful outsourcing of the in-house
community supported living service for
learning disabilities

Lincolnshire County Council

The renegotiation of funding contributions
for services delivered in partnership with
other organisations has enabled the council
to reduce net costs and promote a more
equitable approach to sharing risk between
partners.

The service in Lincolnshire has delivered
savings of £8.981 million in 2012/13 following
savings of over £12 million in 2011/12. This
means savings of over 15 per cent of the
net budget have been achieved over the two
year period. Savings in the second year of
the plan have focused on:
• completing delivery of a fit for purpose
adult social care (ASC) structure in which
staffing has reduced by 25 per cent over
the two years
• closure of all eight of the council’s in-house
older peoples residential homes
• a review of the Lincolnshire Assessment
and Reablement Service

26

• diversion from long-term older peoples’
residential care.
There has also been significantly
improved performance in delivering direct
payments and financial assessments
leading to increased income. Independent
benchmarking has confirmed that
Lincolnshire Adult Social Care has the lowest
management and non-front-line costs of
similar authorities. Significant performance
improvements delivered in 2012/13,
including 100 per cent of eligible people
receiving a personal budget, low admissions
to residential care (6.9 per 1,000 aged
65+), improved outcomes from in-house
reablement service (16 per cent increase in
people successfully reabled and a 5 per cent
decrease in people admitted to hospital from
reablement service).

During 2012/13 a Transformation Unit was
established partly funded by the ASCE
programme. This unit has produced a
blueprint for the Transformation of ASC in
the next two to three years to coincide with
the continued progression of the council to
a ‘Strategic Commissioner’. Two immediate
elements of this Transformation involve
further development of web based systems,
in conjunction with Public Health colleagues,
self-service and increased attention on
prevention and early intervention.

Adult Social Care Efficiency programme Interim report 2013

The service projects to make a further £7.3
million efficiency savings in 2013/14 (5.2 per
cent of net budget).

London Borough of Lambeth
Lambeth aimed through this work to
streamline the adult social care process,
including looking at a more efficient use
of staff resources and easier access to
information and services.
Considerable work has been undertaken
to re-design the service and an outline
operating model for adult social care has
been agreed, with work now focusing on
developing the detailed model. This includes
demand mapping to determine the type and
number of staff required, piloting of an Initial
Contact service and a review of assessment
processes.
The savings target (£5.5 million, 7 per cent
of the net budget) for 2012/13 was met
primarily using savings obtained through
posts vacated through a redundancy and
early retirement process and vacant posts.
Lambeth also made savings by managing
demand through the use of assistive
technology, re-ablement and extra care
housing and by reviewing existing contracts.

Liverpool City Council
The council reports that £13 million of
efficiency savings were achieved in 2012/13
(8 per cent of net budget). This comprises
savings achieved by reviewing eligibility
criteria, signposting users to alternative
provision, improving procurement practices
and reviewing existing care packages.

Luton Borough Council
Luton Council delivered just under £3 million
of savings in 2012/13, 5.9 per cent of the
budget. A further £3.7 million is required for
2013/14, 6.6 per cent of the budget.
Savings have been achieved by more
innovative use of assistive technology and
particularly within learning disability services
which has reaped significant savings.
Savings have also been achieved through
greater investment in respite facilities and
services to support carers; review of inhouse provision and subsequent closure of
all of the council’s older person’s homes;
streamlining of staff structures within
day services; review of all high cost care
packages; contract negotiation with care
providers and restructuring of some teams.
The latter has included a rationalisation of
operational management structures and a
reorganisation of care management using
best practice models. Implementing ‘agile
working’ has significantly reduced the use of
office space and staff travel time.
2013/14 will see an on-going review of
all high cost care packages and out of
borough packages to ensure ordinary
residence legislation is applied. A review will
be undertaken of telecare and telehealth
arrangements to maximise the use of
preventative technology.

Northumberland County
Council
This is a place where the management
of social care services is located within
a Hospital Trust as part of an integrated
community service with local health services.

Adult Social Care Efficiency programme Interim report 2013

27

The initial aim was to see if the impact of
this integrated service could be shown within
the efficiency programme. However, the
impact of the individual elements of the areas
we were interested in as part of the ASCE
program are still being reviewed and it is
proving difficult to attribute success in driving
down costs and activity to any particular
elements as they effect similar outcomes in
terms of activity and spending.
Northumberland have noted that there has
been a 7 per cent fall in the numbers of older
people in placements in residential care /
nursing care placements between April 12
and February 13. This will continue to be
monitored within the programme.

Peterborough City Council
The Adult Social Care Saving programme
for 2012/13 targeted £4.1 million savings
across a range of initiatives. These included
£640,000 savings on improving reablement,
over £700,000 on managing demand by
reviewing care plans, transition planning and
reducing residential and nursing placements.
The latest projection is that savings of £2.9
million will be made against the original
target, representing a shortfall in savings of
£1.2 million, the majority of which was due
to a significant delay in the closure of two
remaining in-house residential care homes.

Poole Council
Poole are focusing on the full savings
programme with a special interest in the
impact that you might have on reducing
the demands of self-funders who run out of
money.

28

The council projected that they would make
savings of £1.4 million in 2012/13 and £1.9
million in 2013/14, 3 per cent of the net
budget. Savings will be achieved in two key
ways.
Firstly work is underway to reshape the Adult
Social Care Helpdesk, in order to resolve
more enquiries at this first point of contact
and avoid further unnecessarily complex and
expensive input.
A programme of activity is also in place to
reduce residential placements made directly
from hospital and create better opportunities
for service users to remain independent at
home for longer. This is supported by a new
approach to more personalised care package
reviews, which will reduce domiciliary care
spend.

Portsmouth City Council
Portsmouth, in part one of the work
looked at efficiency savings achieved
through improved processes and reducing
bureaucracy. The focus in part two has
included personalisation, learning disability
services and reablement.
Savings of £200,000 were made in 2012/13,
achieved through the review of assessments
and care plans. The council have found
that the methodology deployed in reviewing
current practice as part of the transformation
has increased staff buy in and improved
the implementation of improvements.
The hypothesis that customer service
could improve through efficiencies, which
historically have been considered ‘cuts’, have
largely been proved.

Adult Social Care Efficiency programme Interim report 2013

Royal Borough of Richmond
Upon Thames
Despite the fact that Richmond already had
a good re-ablement service their aim was
to improve it further. They have worked with
Health to combine local authority services
that support hospital discharges and offers
re-ablement with the health community
services which look to avoid hospital
admissions and support speedy discharges.
They are looking to improve services which
already perform well with this process of
integration. A consultant was appointed to
challenge existing services and support the
council to develop an integrated Community
Rehabilitation service, which was then
launched in spring 2012.
In July 2012, the council agreed to carry out a
feasibility study with Hounslow and Richmond
Councils, Hounslow and Richmond Clinical
Commissioning Groups and Hounslow and
Richmond Community Healthcare NHS Trust
about the future development of an Integrated
Care Organisation (ICO). The ICO would
encompass the Community Rehabilitation
Service, but would integrate health and
social care services on a much wider scale.
In February 2013, all partners agreed to
commence work on the full business case
for the ICO, following the completion of the
feasibility study.
It has been agreed that the implementation of
the Community Rehabilitation Service would
continue and form an early part of the ICO’s
range of services. The service specification
for the new integrated service has been
agreed by all partners. The new service
will deliver a person-centred integrated
community rehabilitation service, building on
the best aspects of the borough’s reablement

and community health intermediate care
services. This should offer older people a
clear care pathway for hospital discharge
and the opportunity to receive the level and
intensity of rehabilitation services at the
time and for the duration they need it, from
appropriate highly skilled workers.
The multi-disciplinary team will perform the
following functions:
1. hospital discharge and early supported
discharge
2. crisis and rapid response
3. community rehabilitation support.
Efficiency savings of £1.6 million (2.7 per
cent of net budget) were achieved in 2012/13
and a further £1.7 million (2.9 per cent of net
budget) is projected for 2013/14.

Solihull Council
Solihull aimed to reduce demand for services
for older people, with a particular emphasis
on telecare. This has been achieved
predominantly through a review of 179 high
cost care packages, a full case review, a
review of block contracts, modernisation of
day service provision and the application of
lean principles to home care / reablement
processes. The council have also increased
the use of assistive technology adopted
within care and support packages replacing
traditional forms of provision.
Efficiency savings of £1.5 million (2.9 per
cent of the net budget) were achieved in
2012/13. A further £3.1 million is projected
for 2013/14 (5.7 per cent of net budget) and
£1.6 million (3 per cent of net budget) for
2014/15.

Adult Social Care Efficiency programme Interim report 2013

29

The development of the Assistive Technology
and Telecare Strategy and Business Case
provides a clear road-map to developing the
service and achieving savings in 2013/14
and beyond. Further savings will be achieved
by the continued review of high cost care
packages and retender of the current
domiciliary care contract, leading to an
overall reduction in the cost per unit.
Solihull reports that some savings identified
in their Medium Term Financial Strategy for
2012/13 have proved problematic. These
includes savings relating to transport, service
management, domiciliary care re-tender and
community recovery team

Southend on Sea Borough
Council
During 2012/13 £3.7 million of savings
have been achieved, 8.2 per cent of the
net budget. The council have increased
reablement, reviewed in house provision
of services and reviewed residential and
domiciliary care prices. Further work on
these areas is projected to realise additional
savings of £3.3 million in 2013/14.

arrangements. The council were unable to
restrict care price increases as envisaged
therefore predicted savings were not
achieved in this area.
In order to meet budgets reductions for
2014/15 (£9.5 million) and 2015/16 (£12.5
million) the council are implementing a new
operating model for adult care, “Supporting
Lives, Connecting Communities”, which aims
to reduce or delay demand for services.
The model focuses on helping people
to help themselves by providing better
information, prevention / early intervention
and reablement.
The model has been piloted and feedback
indicates that it reduces waiting times,
alleviates confusion and improves
consistency for customers and provides
more person-centred services.

South Tyneside Council

Suffolk County Council

South Tyneside Council aimed to reduce
demand for older people’s services and
in particular, admissions to residential
care. A consultant was appointed to
review admissions and suggest potential
efficiencies. Recommendations included
the development of extra care facilities
with specialist dementia carers, a Rapid
Response team, a Joint Carers Support
Team and the further development of stepdown facilities to provide additional time for
older people to convalesce.

The council chose to undertake a full
service review, with a particular focus
on demand management and work with
Health. Projected savings of £12 million
for 2012/13 are on track to be achieved.
Savings were achieved through improved
contract management and procurement

Through a clearer understanding of demand
the council have tightened admissions to
residential care and in 2012/13 achieved a
29 per cent reduction from 12.2 per 1,000
(2011/12) to 8.7 per 1,000. This equates to
96 fewer people aged 65+ being admitted to
residential care.

It is felt that the lack of re-ablement capacity
has been an obstacle to the progress of
this work. The council are in the process of
growing the market for this service.

30

Adult Social Care Efficiency programme Interim report 2013

In 2012/13 £3.5 million has been saved,
7.7 per cent of the net budget. Savings
were achieved through the review of care
packages to maximise independence,
consistent application of eligibility criteria and
implementation of a new model for day care
and support in the community.
Further savings are projected for 2013/14
(£2.5 million, 5.5 per cent of the net budget)
arising from a review of complex cases,
reconfiguration of home support services
and a review of commissioning fees from the
Clinical Commissioning Group.
Longer-term projects, such as the
development of the new model for
Dementia Services, are felt to be key to the
sustainability of adult social care services in
the area. The council believe that the model
will provide essential services while helping
to manage demand more effectively.

Staffordshire County Council
Staffordshire are one of the Personal Health
Budget (PHB) pilot sites. As part of this they
have been financially supported to raise
awareness of personal health budgets,
both in Staffordshire and across the region
through organising training and events to
provide information. These three training
courses and four events were subscribed
to by approximately 250 people from within
Staffordshire and surrounding authorities.
All five Clinical Commissioning Groups
in Staffordshire are supporting the local
authority to lead on PHBs. Staffordshire is
now considered an early-implementer as
they have all the necessary powers to set
up personal health budgets including direct
payment powers.

There are six people currently holding a
personal health budget in Staffordshire,
with 11 people having had one since the
Staffordshire pilot began. Unfortunately at
this stage it is too early to indicate savings
arising from this move to Personal Health
Budgets

Swindon Borough Council
Through their engagement on the
programme Swindon reviewed their full
savings programme with a particular focus
on the “demand inquiry” and reducing costs
in learning disability services.
Stage 2 of the programme is looking to take
forward the initial analysis of the RAS and
Support Planning forward and implement
recommendations to modernise both in line
with agreed proposals to Members. It is
recognised that the RAS in isolation will not
lead to more personalised outcomes and that
cultural change will be required in operational
practice to enable the change to take place.
The aim is to work with partners to transform
care provision to enable people to make
personalised choices on how they want
to be supported whilst also enabling the
council to live within its financial envelope.
This means giving people more choice and
control, increasing the value and return on
council investment and looking at different
outcomes to meet care needs. There is also
an expectation that costs will fall by 7.5 per
cent. An initial approach has been agreed
and is being analysed. Learning Disabilities
is a client group which is requiring more
analysis to ensure the RAS will work fairly for
that group of clients.

Adult Social Care Efficiency programme Interim report 2013

31

Efficiency savings of 7.1 per cent of net
budget were achieved in 2012/13 and
further savings of 6.3 per cent of budget are
projected for 2013/14. A significant proportion
of the savings were achieved through
reviewing contracts and further outsourcing
of services.

Tameside Council
The savings that were delivered were
those identified as a result of the Financial
Stress Test that Ernst &Young undertook
on Tameside Adult Services. The funding
received from the ASCE programme
contributed to this piece of work. Ernst &
Young were also selected to work with the
council to undertake a future sustainability
financial stress test on the adult social care
system. This revealed that the council had
adopted a proactive approach in making
significant efficiency savings in adult
social care over the past 10 years. They
acknowledged that 90 per cent of adult social
care interventions had been externalised
and provided in the social care market place.
They reviewed the savings programme that
was in place for 2012/2013 and agreed
that it was realistic, viable and achievable.
Ernst & Young identified further efficiencies
and savings potential of approximately £2.2
million.
In 2012/13 the council made significant
efficiency savings equating to £5.9 million,
11.3 per cent of the net budget. Savings
were achieved by the rationalisation of day
services for people with learning disabilities
and review of all older people homecare
packages. £1.8 million was achieved through
staff reductions.

32

Torbay Council
Torbay Council chose to focus their project
on reablement for older people. Extensive
staff development has been undertaken with
the Virtual Review Team and Intensive Home
Support Service. The former have focused
on appropriately reducing packages of care
for domiciliary and day care clients. Savings
are estimated at £100,000 for this team. A six
monthly evaluation is underway and is likely
to result in a change to referral criteria.
The Adult Social Care Commissioning
Team is currently designing outcome based
contracts and contracts for domiciliary and
day care services will be developed in this
way. At present, the level of domiciliary
care savings achieved are not meeting the
anticipated/required level. The council have,
however, managed demand and seen no
growth in 12/13. The process adopted by
the Virtual Review Team needs roll-out to all
frontline social care staff if the council are
to achieve the size of savings required for
2013/14.

London Borough of Waltham
Forest
Through the ASCE programme Waltham
Forest aimed to undertake a full service
review of adult social care.
Efficiency savings of £2.3 million and
£2.9 million are projected for 2012/13 and
2013/14, 2.3 per cent and 2.7 per cent of
the net budget respectively. Savings in
2012/13 have been achieved by re-modelling
of reablement and in house residential
provision, re-structuring of staff and back
office support and better commissioning and
contract arrangements.

Adult Social Care Efficiency programme Interim report 2013

Further savings will be achieved in 2013/14
through remodelling of day care services,
better use of technology and a review of
charges.

Warrington Borough Council
Following the Phase 1 diagnostic the council
awarded a contract to Charteris who are
engaged from March to August 2013 to
review savings made to date and determine
the scope for further savings in adult social
care.
During 2012/13 the council saved ÂŁ2.9
million from a net budget of ÂŁ45 million (6.4
per cent). The range of savings include:
establishing a social enterprise for in house
services ; increased use of intermediate care;
expansion of telecare service; supported
living remodelling; review of day care;
effective targeted commissioning of high
cost packages; changing eligibility criteria;
charging review; expansion of reablement
service; reduce transport costs; review fairer
charging policies.
In the coming year (2013/14) the council
project to save a further ÂŁ2.7 million through
the continuation of projects outline above.
Warrington identify a number of political and
operational considerations that impact upon
timescales for delivering savings, including
consultation timescales and the risk of
legal challenge from both customers and
providers. The range of savings suggestions
also requires resource to be able to deliver
changes in a timely manner.
The table in Annex A looks to summarise
these statements so councils working in
similar areas can network with each other.

Adult Social Care Efficiency programme Interim report 2013

33

5. Two more detailed case
studies
Introduction
At the end of the first phase of the
programme the work that had been
undertaken in Wiltshire and Kingston upon
Thames was showcased at the launch of
the first ASCE programme report, ‘The Initial
Position’. The LGA decided to write up as
case studies the two presentations that were
offered. This is a copy of these case studies.
They were produced in January 2013 and so
more progress and further learning will have
been established since then. They try and
offer a little bit more depth for the reader on
how two councils have approached this task
– quite differently!

Case Study One: Royal
Borough of Kingston-uponThames
This case study has been produced by
the LGA in partnership with Kingston
Borough Council based on a presentation
given by Kingston at the LGA ASCE event
in November 2012. The learning from
Kingston is around the importance of
having a robust analysis of the patterns of
delivery of care when considering areas
where a council could be more efficient
and effective. The learning that Kingston
were able to gain from a robust diagnostic
undertaken by an independent consultancy
enabled them to find areas for savings
which may not have been obvious to them
before. The improvements that are now
being made in Kingston (as a result of the
diagnostic) include changes in practice
for front line staff as well as different
approaches to procurement of services.

Kingston Diagnostic
Kingston is a small London Borough with
an adult social care budget of £53 million.
They have an integrated care trust where
the Director also is the accountable officer
for the local Clinical Commissioning Group.
The council had started to make significant
savings in their budgets since 2008. In
2010 they reported £1 million saved through
reductions in staffing.

34

Adult Social Care Efficiency programme Interim report 2013

They continue to make savings through
shared services and reducing administration
and support functions.
For the LGA programme they paid a
consultancy (Newton (Europe) – after a
competitive tendering process – the £20,000
grant they had received to undertake a full
diagnostic of their activity and outcomes in
adult social care. The diagnostic took three
weeks to complete with “no stone unturned”
as the assistant director responsible for the
adult services Simon Pearce reported. The
diagnostic identified £2.7 million additional
(new) savings for the council, a further 5
per cent of the budget, through improved
efficiency in the way they did things.
Kingston went out to tender again to find
a partner who would actually support the
delivery of the savings. On the second tender
Newton were also successful and have now
embarked in supporting the council to deliver
the targeted savings.
There are some interesting observations
from the approach taken by Newton with
Kingston. The diagnostic showed a number
of facts about which the council had not fully
been aware:
Efficiencies from assessment and care
management
• Care managers in Kingston could have
avoided the deterioration of a number
of client situations if they had offered
appropriate support to carers.
• Care managers prescribed very
different solutions for clients with similar
assessments – one care manager would
regularly find solutions to meet people’s
care needs at much lower cost than
another.

• There was a significant underuse of
telecare by most care managers.
• The re-ablement and in-house domiciliary
care service could be more productive and
the care pathway through re-ablement
needed to be more consistently applied.
• Reviews were often late. They missed
opportunities to measure the progress
people were making and therefore to
reduce the size of care packages.
Savings from commissioning and
procurement
• Domiciliary care providers had a lot of
costs tied up with travel – this could be
reduced making significant savings if a
district model for allocating domiciliary care
was adopted.
• Domiciliary care provision was mostly
managed through spot contracts which
incurred unnecessary costs and did not
incentivise providers to actively manage
improved outcomes for service users.
• There were savings that could be obtained
from better use of the transport fleet.
• The council’s rules relating to the ceiling
rates for older peoples residential and
nursing care were sometimes not adhered
to and there was an opportunity to
renegotiate these.
• There were savings to be obtained through
both better procurement of residential and
supported living for adults with learning
difficulties.

Total
Kingston has now commissioned Newton
(Europe) to support the delivery of the
savings that were identified. The contract
states that Newton will only get paid after
they have delivered cashable savings on a
no savings no fee basis.
Lessons from Kingston
A thorough diagnostic of the activity and
finances of adult social care can be a really
helpful tool to focus the council on where
efficiencies and savings may be found.
Some of the savings rest with procurement
but there is still much to save from improved
practice on the ground. Identifying those care
managers who can deliver better outcomes
at lower cost is part of the challenge.

36

£124,000
£ 75,000
£ 95,000

Targeted prevention is a critical tool for all of
adult social care – this includes getting the
right care pathway for all customers, getting
the maximum use from the investment in
reablement and ensuring that investment
is made in carers to avoid breakdown and
much higher longer term costs.
Commissioning domiciliary care on a district
basis is a good way of approaching a more
cost effective service.
Having a dedicated, full-time project team
to support the assessment and delivery
of efficiencies allows for a more rigorous
diagnostic and faster implementation.

Adult Social Care Efficiency programme Interim report 2013

Case Study Two:
Wiltshire county Council
This case study has been produced by the
LGA in partnership with Wiltshire County
Council. The information has been taken
from a presentation which was delivered by
staff from Wiltshire at an LGA conference
in November 2012. The approach
taken by Wiltshire is usually described
as “outcomes based commissioning”.
However, it offers more than that. It shows
how through interventions that focus on
recovery and promoting independence
that many older people will need less
care. The initial intervention is not limited
to a six week recovery period but takes
as long as is necessary to support the
person. Providers are paid for the nature
of the interventions that they offer in each
individual case. The onus is on the provider
to identify the best interventions that are
most likely to help the older person regain
more independence. The interventions
may be based on reablement domiciliary
care; but they might also include telecare
and appropriate equipment; support to be
integrated back into community life (tackling
social isolation); housing repair or alternative
accommodation; or other appropriate
actions that will rebuild confidence and
enable a person to live a fulfilled life in their
community. The programme is in its first
year and has enabled Wiltshire to deliver
the savings that were required to balance
the previous overspent adult care budgets
and to improve the quality and experience
of older people who needed some care and
support in the county. The figures indicate
a saving of around 10 per cent in the spend
on domiciliary care since the inception of
the programme with much higher user
satisfaction rates also reported.

The new approach in Wiltshire
Wiltshire Council has replaced traditional
community care services for older people
with an integrated system of care and
support. Help to Live at Home (H2LAH)
reconciles three competing aims of social
care reform: personalisation, recovery and
prevention.
Assessments are now person-centred and
focus on outcomes, especially outcomes
that leave customers better able to live
well with less care. The aim is first to help
people recover their independence and
second to reduce their reliance on care
and stop it from increasing. In H2LAH
reablement is not a special kind of service:
it is the aim of all the council’s services.
H2LAH pays providers for the results
they achieve. Results are outcomes that
improve or preserve independence. The
council applies financial penalties when
customers’ outcomes are not achieved and
rewards care providers when customers
recover faster than planned.
Wiltshire Council believes that buying
outcomes instead of hours is a commercial
incentive to improve the pay and skills of
the care workforce.

Adult Social Care Efficiency programme Interim report 2013

37

25%

25%

1 The problems of20%
the past
The system in Wiltshire was previously
characterised by:

In 2009 Wiltshire Council held an event
22%
with various representatives from every part
of the care and support system, including
customers, 10%
social care providers, local NHS
providers, politicians and commissioners.
5%
They
asked stakeholders to tell them what
they thought about the services and how it
mightPrevention
be improved. A lot of feedback
Other was
collected but some very strong themes
came up consistently and were confirmed
repeatedly during the development of the
service. Throughout the change process
Wiltshire has retained a customer reference
group who have commented and contributed
to each stage of the change process (and
are still active today when the project is now
a mainstream service).

£3,400

3

38

£800
Level of need

Level of need

£3,200

6
Time (months)

9

12

Adult Social Care Efficiency programme Interim report 2013

3

6
Time (months)

9

12

The top left-hand graph represents a crisis2,
when a customer needs most support. The
blue line shows their needs reduce as they
recover. In traditional systems, decisions
about long-term care happen near the top
of the “needs curve.” At this point a decision
is made about kind and intensity of care the
person needs. Support then is provided at
that level but, for people who then begin to
recover, it is frequently left unchanged. The
old system maintained this level of support,
designed to meet a high level of need, for too
long — in some cases 12 months or longer.
This is true of decisions that are taken in local
authority assessment and care management.
It is also true of people who buy care without
asking their local authority for a statutory
assessment. While not all customers improve
in this way, we know our systems were not
good at finding those that do. Councils are
good at responding to increased needs, but
our processes are not defined to identify
improvement and reduce support when
people get better. The pink areas represent
the financial waste if a person who recovers
from their crisis is not reviewed for six months.
Wiltshire found that the longer a customer
has things done for them that they can do
for themselves the more, over time, they will
come to depend on their care. This is a form
of institutionalisation.
The graph to the right shows a better
alignment of activity and need through time.
Reviews are more frequent and the package
of support is adjusted more often. Regular
reviews dramatically reduce the amount of
money being spent on unnecessary care.
There is still some waste.

This, however, leaves Wiltshire with two
problems:
1. What front-line adult care service can
review at this frequency? (And would
customers really want so much intrusion?)
2. Care providers’ business models generate
profits from activity; a model that promotes
independence and eliminates waste
threatens their revenues.
Wiltshire decided that they needed a product
that would solve these problems by changing
the financial incentives for providers and not
by drastically increasing reviews. Their view
was that the objective of eliminating waste
would be better achieved by tying providers’
revenues to outcomes that maximise
independence. Payment by results provided
one solution. Providers are required to take
financial risks on customers’ independence.
Wiltshire determined that Providers should
assist older people to achieve the basic
outcomes that enabled them to carry on
managing for themselves the activities of
daily life.
So Wiltshire’s “Payable Outcomes” are
about simple activities of daily living —
getting up; bathing; dressing; cooking and
eating; shopping; seeing friends and family.
If a customer struggles with these tasks
because they are frightened —perhaps they
fell in the bath and are afraid to fall again
— or because they have never looked after
themselves — perhaps they were bereaved
— our providers’ success is measured by
what the person can do and not, directly, by
what they feel.

2 This model was developed by an independent consultancy –
Charteris that supported Wiltshire through the early stages of
this development. Unfortunately though the individuals who did
this work are still within the care sector the company no longer
works within adult social care.

Adult Social Care Efficiency programme Interim report 2013

39

2. The new model

Council
Assesses
& Agrees
Outcomes

Providers
Support
plan

Council
Authorities

Council
decides on
payment

Providers
Review

This diagram summarises the H2LAH process and highlights the council’s and the providers’
responsibilities and interaction.

40

West 2

North 2

So the Wiltshire model for “Helped to Live
at Home” is based on paying providers to
deliver the outcomes for which older people
had been assessed by the local authority.
It is based on the
19 principle that many older
7
33
people can become more
51 independent if
their care is delivered to them in a way that
supports (not undermines) their recovery. It
9
is a system that therefore pays by the results
3
delivered
– the results to7 be delivered as part
13
of the assessment and always agreed with
14
3 potential recipient of
the
17the service – the
7
older person.
North 1

West 1

South 2

South 1

East 1

All

Older People said they want help quickly in
a crisis. In Wiltshire the “Initial Assessments”
are short and quick so that providers can
No further
support needed
start work
with customers
soon after they ask
for help.
Theorperiod
from the
beginning of an
Same
more support
needed
Initial Assessment to the agreement of an
Less support needed
Initial Support Plan should be no more than
six days.

Near the end of the support plan the provider
reviews the customer to see if outcomes
were achieved. The council checks the
review with the customer, visiting them if
there is any doubt. If they determine that
outcomes haven’t been met, and this is the
provider’s fault, they may apply penalty to
their next payment.

East 2

H2LAH uses a familiar social care
assessment and care management
process. The model lays out the clear roles
and responsibilities for the customer, the
council and care providers. Assessments
determine eligible needs but, unlike
traditional community care assessments,
they ask people what they want from their
care. Support Plans are initially written by
assessment staff with customers. These
stipulate the outcomes that are to be
100%
delivered. The providers then use the support
plan with the customer explaining how they
will80%
work to achieve the outcomes;18how long
176 and13how much the plan will
they will need;
18
17
60%
cost. The providers are paid according to
these outcomes. The weekly price of the plan
40%customer’s Personal Budget, which
is the
8 if they
53 as a3Direct Payment
they may take
do 20%
not want services from 4their local “Help to
6
5
53 provider.
5
Live at Home”
2

The outcome, and the reason for the
outcome, must be easily observed and
agreed; and it must result in the person
being as independent as they can be.
We when the assessment staff review
outcomes, they check that what was agreed
in the assessment — being clean; learning

Adult Social Care Efficiency programme Interim report 2013

how to cook a meal; not falling in the bath
—occurred in reality. They are directly
observable. Capability in these areas makes
the difference between dependence and
independence.

Person-centred assessments make it easier
for customers to tell us what they want from
their support. They encourage people to
think about ends (outcomes) before they
think about means (services).

Decisions on payment by results are part
of the statutory review and reassessment
process. When a plan ends the provider
tells the authority what happened with the
outcomes. The authority checks with the
customer and decides whether they were
or weren’t achieved. If they weren’t, the
county decides if the provider caused the
failure. If the provider was clearly responsible
for the failure, operational managers may
choose to apply a penalty that is deducted
from the provider’s next payment. Providers
may appeal through formal contracts
management. The penalty for initial support
plans is 80 per cent; the penalty for on-going
support plans is 15 per cent.

H2LAH is more equitable than the service
it replaces. There is no means-test when
people approach Wiltshire needing shortterm support during a crisis. H2LAH “Initial
Support” is free for all those whose level of
need is eligible for public support. People
who would otherwise be self-funders
benefit from having the right care and leave
decisions about long-term care until the crisis
is past. A good decision at this point reduces
the likelihood that people will use long-term
care too early and so of needing council
funding when their funds are exhausted

The model penalises failure, but does not
penalise success. If providers achieve
outcomes using fewer resources than was
agreed, the authority does recover the
excess. This means that the agreement
about the initial support plans is very
important. It also encourages the providers
to innovate and find less costly ways of
achieving outcomes during delivery.
The traditional distinction of “reablement” and
domiciliary care services has been replaced
with “Improvement” and “Maintenance”
that are used in payment by results. They
create a financial incentive to help reduce
customers’ need for care, rather than
guarding the numbers of hours that they
deliver. H2LAH replaces traditional care
assessments, with their focus on what people
can’t do and services that will meet their
needs, with person-centred assessments.

The council has simplified its trading
relationship with the provider market. We
now provide reablement and care at home,
housing support, equipment, Telecare and
response services with six organisations.
Ninety separate and very different dom.
contracts worth £14 million have been
reduced to eight very similar payment-byresults contracts worth £11 million with four
of those six organisations. (The other two
organisations provide equipment, small
adaptations, Telecare emergency response
that is used by the four care providers in
holistic support plans.)
Providers have access to the council’s
Carefirst case management system, which
manages the whole assessment, supportplanning, purchasing, review and payment
process. The data from this process are
used in an online performance management
system used by providers and council. This
system gives daily and detailed updates on
the performance of H2LAH.

Adult Social Care Efficiency programme Interim report 2013

41

Council
decides on
payment

17

7

West 2

51

The results
14

3
6

West 2

53
20%

17

No further support needed

2

5

4
3
53

North 2

40%

7

14
60%

3

7

Less support needed

5

8

18
176

6

North 1

South 1

2

5

80%

East 1

4

100%

5

13

East 2

53

20%

7

13

3
17

18
13

9

3

8

West 1

3

South 2

53

All

Council
Assesses
& Agrees
Outcomes

40%

Same or more support needed

9

19

7

Council
Authorities

33

51

All

60%

East 1

Providers
Support
plan

33

17

South 1

18

19

South 2

13

7

West 1

176

18

East 2

80%

North 1

100%

North 2

Providers
Review

Wiltshire have reported a reduction of £1 million in the spend on domiciliary care during
the first six months of the full operation of their new service. This is equivalent to 3 per cent
reduction of spend. (Wiltshire had previously reduced the costs of domiciliary care by 7.5 per
cent through the tendering process for the contracts for the H2LAH service.)

No further support needed
or more support
needed
Since Same
the services
were put
in place:

Conclusions

Less support needed

• 61 per cent did not need on-going care
• 19 per cent needed on-going support but it
cost less per week than initial support
• 20 per cent needed on-going support that
cost more per week than initial support
• 12 customers left the H2LAH service and
moved to a care home
• the average price for initial support was
£1,200.
These figures would be impressive for any
straight forward domiciliary care re-ablement
service with the unit costs reported much
lower than previously reported English
Averages (between £1,500 – £2,000).

42

H2LAH is not one discrete area of the
council’s adult care activity – it integrates a
number of different services. There is a clear
definition of the responsibilities of the council,
customers and providers. There is an
emphasis on partnership between the three
in order to deliver the most effective quality
care. It is designed to give providers a clear
financial incentive to focus on customers’
outcomes, especially the outcomes of
independence, by delivering quality care.

Adult Social Care Efficiency programme Interim report 2013

Annex A: Summary
of progress to date
Areas where savings are being reported and some case
examples
The following areas are those reported by councils in which they have made savings:
Category of savings

Efficiency savings

Examples of council(s)
undertaking work in this area

Reducing bureaucracy
Reducing Staffing:
Reducing staffing and costs of
bureaucracy
Making more efficient use of social
workers time

In 2012/13 half of all
efficiency savings
were said to arise from
reduced bureaucracy. In
2013/14 this is projected
to fall to 43 per cent.

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Telephone 020 7664 3000
Fax 020 7664 3030
Email info@local.gov.uk
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ÂŠ Local Government Association, June 2013

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